Understanding Gender Dysphoria – Part 3

Gender Dysphoria cover“I don’t think you chose to experience gender dysphoria,” I offered slowly, looking at Jeremy who had been looking away ever since he explained how long he had felt different from other boys he knew. He hadn’t held eye contact once since he began talking about the time his mother caught him dressing in his sister’s clothing one day after school. He wouldn’t look at me when he shared how his father confronted him that same night when he came home from work. After I spoke, he turned toward me to catch my eye, as if he wanted to confirm I wasn’t just saying this to make him feel better. You see, he had been told by Christian leaders just the opposite—that he had indeed chosen to feel like a girl; that his experience of gender dysphoria was an act of willful disobedience to be confronted by his parents if they hoped to help him, if they hoped to save him.

It is a remarkable claim to declare that an adolescent is choosing gender dysphoria to make life difficult for his parents or to essentially thumb his nose at God as Creator and at his own body as a part of the creation.

In this blog post I want to introduce the topic of etiology or causation. The question is: What causes someone to experience gender dysphoria? Recall that gender dysphoria refers to the incongruence between one’s biological/birth sex and one’s psychological and emotional experience of gender identity. One possible benefit to discussing causation is to improve the exchanges between Christian leaders and someone like Jeremy.

Let me first acknowledge limitations to research in this area. These limitations should help us take a posture of humility toward the topic of gender dysphoria, toward what we know and what we do not know.

When we discuss who is transgender, we quickly realize that while this is an umbrella term, there is not consensus as to who is transgender. Put differently, there is great heterogeneity among these different phenomena. A range of people  may identify as transgender. In a chapter he wrote on the topic, Richard Carroll recognizes “transsexuals, transvestites, she-males, queers, third sex, two-spirit, drag queens, drag kings, and cross-dressers.” Not all of these folks will experience gender dysphoria, and many would not feel comfortable including everyone else under the umbrella of “transgender.”

How this is related to research on causation? The heterogeneity represented under the transgender umbrella makes it difficult to conduct research on causation. We have to begin by identifying the key variables and then finding ways to operationalize and measure those variables. If we are trying to explain cross-dressing behavior, for example, we have to acknowledge that not everyone who cross-dresses experiences gender dysphoria. Not everyone who identifies as transgender either cross dresses or experiences gender dysphoria.

Most of the research on causation is limited to transsexuals. In some ways this can be helpful, as most transsexual persons presumably experience sufficient gender dysphoria such that they form a cross-gender identity and may pursue hormonal treatment and/or sex reassignment surgery. However, the experience of diagnosable gender dysphoria is rather rare, and finding a sufficient number of transsexual persons for research purposes can be problematic. Most of these studies are conducted with small samples, which is just one of many potential limitations to research in this area.

In any case, the most popular theory of causation today is called the brain-sex theory. The brain-sex theory holds that transsexuality is essentially biological in origin. It might be thought of as (in the words of Milton Diamond) an “intersex condition of the brain.” The theory is based on the understanding that sex differentiation of the genitalia and sex differentiation of the brain occurs at different stages of fetal development. The idea is that perhaps in rare instances the genitals develop in one direction while the brain develops in the other direction.

In support of this theory, the most widely-cited studies have been on neuroanatomical structures of the brain. Proponents believe that differences in size and volume of cells in specific regions of the brain suggest a biological basis for etiology. Other studies in support of the brain-sex theory have been conducted as well, and I discuss these in greater detail in the book that will be out in June.

There are other theories of causation that do not receive as much attention. They tend to be multifactorial models with more consideration given to psychosocial factors. Proponents of these models suggest there are–in addition to prenatal/biological considerations–differences in areas such as temperament, level of anxiety, sensory reactivity, same-gender parental identification and modeling, and early childhood trauma that may also be part of the picture.

I also want to acknowledge that research is not conducted in a vacuum. It is conducted in a sociocultural context. Today that context is one in which identity has emerged as particularly salient. It has figured prominently in what Cressida Heyes refers to as the “gay liberation movement,” which focused historically on equality for gay and lesbian persons: “Visible early lesbian and gay activists emphasized the immutable and essential natures of their sexual identities. For some, they were a distinctively different natural kind of person, with the same rights as heterosexuals (another natural kind) to find fulfillment in marriage, property ownership, and so on.” This kind of focus on identity can also be part of the motivation to conduct research with a focus on biological bases for gender dysphoria. That is, there would then be a more identity-focused discussion of transgender kinds of persons that can be distinguished from cisgender kinds of persons. My sense is that in the minds of many proponents of transgender interests, research on biology lends itself to the kind of argument in favor of an “essential nature” related to gender identity.

I think the most accurate answer to the question of causation is this: We don’t know what causes gender dysphoria. While the research in this area has been going on for many years now, there just is not that much data to point to for a final word on causation.

When I think of Jeremy, the person I was talking to who had been told by Christian leaders that he chose his experience of gender incongruence, I have to urge those who minister to people like him to resist the pressure to have the answer at that moment. It is okay to not know what causes a person’s experience of gender dysphoria. I say this to people all the time. I have found it much more helpful to take a posture of humility about causation and to focus on care. To do this, you could always ask the person, What would it mean for you to know what caused your experiences of gender dysphoria? This question may open up a more helpful discussion of meaning and purpose that may guide efforts to provide support as the person navigates questions of gender identity.


Note: This blog post is Part 3 of a series. If you found this interesting, you may want to read Part 1 and Part 2. Also of interest may be a recent talk I gave at Calvin College titled Understanding Gender Dysphoria. The book I mentioned can be pre-ordered through IVP or Amazon.

The Calvin College Talk on Gender Dysphoria

The AV staff at Calvin College have been working on a better quality video of the talk I gave titled Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture. Here is the video. It is about an hour with some Q&A from the audience:

Several transgender and gender variant people and families who have loved ones who are under the transgender umbrella have reached out to me following the talk. They are hungry for resources and for a way forward.  If I were to summarize the themes from those exchanges so far (and some are ongoing), I would say they are centered on (1) self understanding (How do I understand what I am going through?), (2) the faith community (How do I have more constructive discussions with pastors and others in my church?), and (3) How do I improve existing relationships with loved ones? In some ways these are similar to what we reported in our research with male-to-female transgender Christians a few years ago. I think these themes also line up with what I have seen in counseling individuals, couples, and families over the years.

These are important, significant discussions for every individual and family that is navigating this terrain. So many feel alone and unsure how to even begin a conversation. The section from the presentation on different “lenses” through which different stakeholders “see” the issues and people seemed especially promising to them. There is certainly much more that can be done to be a resource for responsible care in these three areas, and I hope that ongoing discussions and future discussions will be a part of seeing that come about.




Transgender & Gender Variant Youth

flower-in-stonesOver the past two years I’ve been speaking with colleagues at the National Youth Worker’s Convention. This past year I was speaking with Julie Rodgers who works in the chaplain’s office at Wheaton College. We typically co-present a 5-hour intensive, followed by a 1.5 hour breakout workshop and a 30 min interview at the Idea Lab. It has been interesting to reflect on the Frequently Asked Questions (FAQs) that come up in these settings. What are youth ministers really dealing with? What questions do they have? When we conducted a recent study of youth ministers, we did hear interest in learning more about theories of causation and change; however, we asked if they were interested in those questions. What I find interesting is to conduct a workshop and hear what those in attendance actually have on their minds. We did receive a couple of questions like that, but I would say that one common and fascinating theme was actually not about homosexuality or sexual identity. It was about transgender issues and gender variant behaviors.

The question would be something like this: “Our youth group frequently breaks up into smaller groups with guys in one room and girls in another. Well, we recently had a teen visit our youth group who was born male but identifies as female. This teen’s preference is to break out with the females. What should we do?”

The prevalence estimates on transgenderism put it at quite a bit less frequent than sexual identity based on self-report of attractions, behavior, or even identity labels. As we discussed it afterward, it may be more of a reflection of the anxiety of the presentation than the actual frequency of the presentation. However, in one session, this was the actual question asked, so it has occurred in at least one of the youth groups represented at the conference.

I resist the temptation to offer “three easy steps” to navigating gender identity questions that arise in youth group. Transgender and gender variant presentations are going to be a challenge for the church moving forward. It is clearly going to be the next cultural wave that will crest soon over conventionally religious people in a way that will stretch them to think through their own views of the topic, how best to create a place for young people who are navigating that terrain, and how they wish to relate to a broader culture that does not support their presuppositions.

There is a calculus that is involved that is difficult to calculate. One the one hand the Christian community wants to be able to affirm male and female distinctions rooted in the creation narrative and thought to be part of a larger theological anthropology. Evangelical theologians tend to cite these distinctions as important for a Christian ethic centered on both sexual behavior and gender identity, although these are two different discussions in some important ways.

OLYMPUS DIGITAL CAMERAHaving acknowledged the challenge, let me say that youth ministers want answers. What do we do? This is part of the reason why I am drawn to speak at these events. No fluff. I think the most thoughtful accounts from the Christian community will balance both teaching and ministry; theology and pastoral care–in a cultural context that will increasingly not share an identical point of reference with respect to sex and gender norms. As I said to the group in attendance, I don’t have a list of what you should do. I would fall back on a more careful assessment of what is being presented and what is being requested. And churches vary considerably in how they intend to approach divisive topics, how they relate to their local community, and so on. These differences are due to location, theological assumptions, personnel, and key stakeholders. For example, I know of many churches in southern California, for instance, that are trying to be missional in their attempts to accommodate a range of requests that might come from transgender and gender variant persons. Certainly if your youth group is taking that posture in the context of a larger church that has more of a missional approach, such a stance will inform your options and interests in that moment.

A little background: transgender is an umbrella word for many ways in which people might experience themselves as different than those who biological sex and gender identity correspond to establish a kind of congruence. A person could have a strong cross-gender identification with a desire to cross-dress; some may cross-dress to manage dysphoria while others to express their sense of self; still others might experience their gender identity as residing along a continuum rather than a cross-gender identification (a person might think of themselves as genderfluid or genderqueer). Those who are transgender who experience significant gender dysphoria have a serious condition that would likely have brought them under the care of a mental health professional (and possible multidisciplinary professional team including medical professionals). This condition is quite rare and I would want to seek some consultation from those who are working closely with the teen who is demonstrating a preference for one break out group over another (or whatever the question is that we are discussing).

So the place to begin is actually not in offering a definitive answer to where the person should go during a breakout. A place to begin might be, How well do you know the person and how do you best understand the request in the context of your larger mission? That will require a relationship–a sustained relationship in which discussions take place about the experience navigating gender identity questions or concerns. I could imagine working out different solutions with different youth given a number of potentially important variables. Do those in ministry (and parents who support them) have the patience for that kind of ministry care? I hope so. If the church hopes to provide a place for young people to navigate difficult issues in a changing culture, we will have to be rather thoughtful and mature in our responses.

For those who are interested:  I have been working on a book on the topic of transgender and gender variant persons that is due out in 2015. It has been fascinating to conduct background research in this area, as well as to draw upon clinical experiences over the years. I hope it will at least provide information and an integrated framework that will inform how a youth minister or pastor responds to transgender and gender variant people in a culture that is changing in terms of attitudes toward sex and gender norms and presentations. I’ll do a few posts on the topic as we get closer to the release date.